Drug Prescribing For Dentistry Dental Clinical Guidance

Transcription

1 Scottish Dental Clinical Effectiveness Programme SDcep Drug Prescribing For Dentistry Dental Clinical Guidance Second Edition August 2011

2 Scottish Dental Clinical Effectiveness Programme SDcep The Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative of the National Dental Advisory Committee (NDAC) and is supported by the Scottish Government and NHS Education for Scotland. The programme aims to provide user-friendly, evidence-based guidance for the dental profession in Scotland. SDCEP guidance is designed to help the dental team provide improved care for patients by bringing together, in a structured manner, the best available information that is relevant to priority areas in dentistry, and presenting this information in a form that can interpreted easily and implemented. Supporting the dental team to provide quality patient care

3 Scottish Dental Clinical Effectiveness Programme SDcep Drug Prescribing For Dentistry Dental Clinical Guidance Second Edition August 2011

4 Scottish Dental Clinical Effectiveness Programme SDCEP operates within NHS Education for Scotland. You may copy or reproduce the information in this document for use within NHS Scotland and for non-commercial educational purposes. Use of this document for commercial purpose is permitted only with written permission. ISBN First published 2008 Second edition published August 2011 Scottish Dental Clinical Effectiveness Programme Dundee Dental Education Centre, Frankland Building, Small s Wynd, Dundee DD1 4HN [email protected] Tel / Website

5 Drug Prescribing For Dentistry 1 Introduction Scope of this Guidance Medical Emergency Information Prescribing Information Drug Interactions Prescribing For Specific Patient Groups Local Measures Statement of Intent Prescription Writing Adverse Reactions to Drugs Labelling 6 2 Medical Emergencies in Dental Practice Anaphylaxis Treatment of Milder Forms of Allergy Asthma Cardiac Emergencies Acute Coronary Syndromes (Angina and Myocardial Infarction) Cardiac Arrest Epilepsy Faint Hypoglycaemia Other Medical Emergencies Stroke Aspiration and Choking 21 3 Anxiety 23 4 Bacterial Infections Infective Endocarditis Dental Abscess Acute Necrotising Ulcerative Gingivitis and Pericoronitis Sinusitis 32 5 Fungal Infections Pseudomembranous Candidosis and Erythematous Candidosis Denture Stomatitis Angular Cheilitis 39 6 Viral Infections Herpes Simplex Infections Varicella-zoster Infections 44 iii

6 7 Odontogenic Pain 45 8 Facial Pain Trigeminal Neuralgia Other Facial Pain 52 9 Mucosal Ulceration and Inflammation Simple Mouthwashes Antimicrobial Mouthwashes Local Analgesics Topical Corticosteroids Dry Mouth Subjective Dryness but Good Saliva Volume Dry Mouth Induced by Head and Neck Radiotherapy Dental Caries Clinical Governance, CPD and Training Recommendations for Self Audit National Audit 68 Appendix 1 Guidance Development 69 The Scottish Dental Clinical Effectiveness Programme 69 The Guidance Development Group 70 The Programme Development Team 71 Guidance Development Methodology 72 Review and Updating 73 Steering Group 74 Appendix 2 List of Drugs 75 Appendix 3 Useful Sources of Information 77 Index 81 References 83 iv

7 1 Introduction Registered dentists are legally entitled to prescribe from the entirety of the British National Formulary (BNF; and BNF for Children (BNFC; However, dental prescribing within the National Health Service (NHS) is restricted to those drugs contained within the List of Dental Preparations in the Dental Practitioners Formulary (DPF). The DPF was formerly a distinct publication, providing information on prescribing for general dental practitioners. However, since 2005 the DPF advice on dental prescribing has been incorporated into the body of the BNF and BNFC, making this advice available to both medical and dental practitioners. An updated volume of the BNF is published every six months and a new BNFC is published every year, which enables access to the latest prescribing information in print and online. To facilitate easy access to information that is most relevant to drug prescribing for dentistry, the Scottish Dental Clinical Effectiveness Programme (SDCEP; convened a Guidance Development Group in 2005 to produce guidance that brings together the essential information from the BNF and BNFC. Further details about SDCEP and the development of this guidance are given in Appendix 1. Edition one of this guidance was published in April 2008, with updates provided periodically. This second edition of the Drug Prescribing For Dentistry guidance is based on BNF 61 1 and BNFC and supersedes the first edition and its updates. The list of drugs that can be prescribed by dentists within the NHS in Scotland includes all drugs in this guidance (see List of Dental Preparations in BNF 61 1 ). Although dentists can prescribe additional drugs within the NHS, they have a duty to prescribe only within their competence and to adhere to guidance from their local formulary committees. 1.1 Scope of this Guidance This guidance aims to facilitate drug prescribing within primary care dental practice by bringing together advice on dental prescribing from the BNF and BNFC and presenting it in a readily accessible, problem-orientated style. The information on drug prescribing contained in this guidance is based on BNF 61 1 and BNFC , whose advice is constructed from the clinical literature and reflects, as far as possible, an evaluation of the evidence from diverse sources. The drugs recommended in this guidance were identified by the Guidance Development Group as most relevant to primary care dental practice. Advice on drugs used to manage medical emergencies is also provided. This advice is based on information provided in BNF 61 1 and BNFC , and guidance published by the Resuscitation Council (UK) 3. This guidance is suitable for informing dental practitioners in the primary care sector, and applies to all patients, including adults, children and those with special needs, who would normally be treated in the primary care sector. The guidance does not include advice on prescribing for those in a secondary care environment or for practitioners with special expertise who may prescribe a wider range of drugs. 1

8 1 Introduction Drug regimens with dosages are included but the intention is for this guidance to be used in conjunction with the BNF and BNFC. Consult the most up-to-date volume of the BNF (published every 6 months; before prescribing for adults and be aware that prescribing for some patient groups, including the elderly, patients who are pregnant and nursing mothers, might differ (see Section 1.1.4). Consult the most up-to-date volume of the BNFC (published annually; before prescribing for children Medical Emergency Information All general dental practitioners and dental care professionals are required to be able to manage medical emergencies, which includes the administration of drugs in a life threatening situation. A list of drugs for use in medical emergencies is included in Section 2, together with information about their administration. This list reflects the emergency drugs recommended in BNF 61 1 and in Resuscitation Council (UK) guidance 3, and supersedes the list of emergency drugs included in NDAC guidance 4 published in In addition, brief details of the signs and symptoms of medical emergencies that might occur in primary care dental practice are provided. Information regarding administration of drugs used in medical emergencies is provided in white boxes on the left, with any differences in the doses or formulations for children provided in blue boxes on the right. This advice is based on information provided in BNF 61 1 and BNFC , and guidance published by the Resuscitation Council (UK) 3. Refer to guidance from the Resuscitation Council (UK) 3 ( for more detailed advice on how to recognise, assess and manage medical emergencies and for details of the equipment and training required to be able to deal with medical emergencies and resuscitation effectively. The SDCEP Practice Support Manual 5 ( also contains further information and guidance concerning medical emergencies and life support Prescribing Information In Sections 3 11, prescribing information is presented for all patients: information is provided for adults in yellow boxes on the left, and differences in the doses and formulations used for different age ranges of children are provided in blue boxes on the right. This advice is based on BNF 61 1 and BNFC For those drugs where a range in the dose or frequency of administration is provided by the BNF, a dose and frequency of administration that is most relevant to primary care dental practice is recommended based on the opinion of experienced practitioners. Advisory notes and cautions are provided in footnotes to the prescribing boxes to help inform the decision of the practitioner. For more-detailed information on cautions, contraindications and side-effects, refer to the BNF ( and BNFC ( 2

9 1 Introduction For practical reasons, the frequency of administration of each drug is generally given as X times daily. However, it is advisable to inform patients that they should take the drug at regular intervals that are as spaced out as possible. In some cases a drug of choice is recommended for a given dental condition. However, in many cases drug regimens are not listed in order of preference so that the choice of the clinical practitioner is not limited. The availability of sugar-free preparations, as indicated in the BNF, is highlighted; for further details, refer to the BNF ( and BNFC ( A list of all the drugs recommended in this guidance is provided in Appendix Drug Interactions Common drug interactions that could have serious consequences are identified within the guidance and include: interaction of non-steroidal anti-inflammatory drugs (NSAIDs), azole antifungals and antibiotics with warfarin. incidence of myopathy after prescribing azoles, erythromycin and clarithromycin in those taking statins. asthma symptoms exacerbated following the use of NSAIDs. It is important that dentists are aware of potential drug interactions. Therefore, please refer to Appendix 1 of the BNF ( and BNFC ( for comprehensive information on drug interactions. Note that antibiotics which do not induce liver enzymes are no longer thought to reduce the efficacy of combined oral contraceptives. See section 4 for further information Prescribing For Specific Patient Groups Be aware that prescribing for the elderly, patients who are pregnant and nursing mothers might differ from prescribing for the general adult population. Also note that dentists need to be aware of whether any patient suffers from an unrelated medical condition (e.g. renal or liver impairment) or is taking other medication because modification to the management of the patient s dental condition might be required 6. Refer to the BNF ( and BNFC ( for further details. 3

10 1 Introduction Local Measures Drug therapy is only part of the management of dental conditions, which also includes surgical and local measures. In some cases, local measures are sufficient to treat a given dental condition, whereas in other cases drug therapy in addition to local measures is necessary. Information regarding common local measures to be used in the first instance is provided in green boxes before prescribing information. 1.2 Statement of Intent This guidance is based on information contained in BNF 61 1 and BNFC and the opinion of experts and experienced practitioners, and reflects current relevant legislation and professional regulations. It should be used in conjunction with the BNF and BNFC and be taken into account when making decisions about a particular clinical procedure or treatment plan in discussion with the patient and/or guardian or carer. Note that some drugs, although licensed, are recommended for use outside the terms of their licence ( off-label use). Some of these drugs have been found to be effective in dental practice but their specific use in dentistry has not been licensed. Also, certain drugs which are licensed for use in adults are not licensed for use in children. As most drugs are not usually tested on children, pharmaceutical companies cannot apply to license them for paediatric use. The use of these drugs is, however, sometimes necessary in the treatment of children. For more details see the General Medical Council website: faqs.asp#10. The responsibility for prescribing drugs off-label and any other drugs lies with the practitioner who signs the prescription. Note that prescribing or administering drugs that are unlicensed for a particular condition or for use in children alters (and probably increases) the practitioner s professional responsibility and potential liability, and the practitioner should be able to justify and feel competent in using such drugs (see BNF; For information, these drugs are indicated within the text. Also note that drug therapy is only part of the management of dental conditions, which also includes surgical and local measures. As guidance, the information presented here does not override the individual responsibility of the health professional to make decisions appropriate to the individual patient. However, it is advised that significant departures from this guidance be fully documented in the patient s case notes at the time the relevant decision is made. 4

11 1 Introduction 1.3 Prescription Writing Dentists may only write NHS prescriptions for drugs which appear in the Dental Practitioners Formulary (DPF), which is incorporated in the BNF ( and BNFC ( NHS prescriptions are written on a specified form (e.g. GP14 in Scotland). If the medicine to be prescribed is not included in the DPF, a private prescription may be provided. Private patients who require medicine as part of their treatment should also be provided with a private prescription, even if the required drug is included in the DPF. Private prescriptions may be written on practice headed notepaper following the same recommendations as for NHS prescriptions. Dental practitioners may only prescribe using the non-proprietary name of the drug. Exceptions to this are detailed in the text under individual drugs. Write prescriptions legibly in ink, stating the date, the name and address of the patient and the practice address. It is preferable that the age and date of birth of the patient is also stated; this is a legal requirement in the case of prescription-only medicines for children under 12 years. State the dose and dose frequency; the quantity to be supplied may be indicated by stating the number of days of treatment required in the box provided on NHS forms. In the case of preparations to be taken as required, specify a minimum dose interval and the total quantity to be supplied. Write the names of drugs and preparations clearly using approved titles only. Do not use abbreviations. Sign the prescription in ink. There is no statutory requirement for the dental surgeon to communicate with a patient s medical practitioner when prescribing for dental use. There are, however, occasions when this would be in the patient s interest and such communication is encouraged. There are no clinical indications for drugs which have controlled drug prescription requirements to be prescribed in primary dental care. NHS prescription pads must be kept secure to prevent misuse or theft. Further advice on prescription writing is given in the BNF ( and BNFC ( 5

12 1 Introduction 1.4 Adverse Reactions to Drugs Adverse or unwanted reactions might occur after use of any drug. The Medicines and Healthcare products Regulatory Agency (MHRA; monitors suspected adverse drug reactions through the Yellow Card Scheme ( Healthcare professionals are advised to record and report any adverse drug reactions using the scheme. More information is available from the BNF ( 1.5 Labelling As of BNF 61 1, a revised set of advisory and cautionary labels has been introduced. All of the existing labels have been user-tested and the revised wording reflects terminology that is better understood by patients. 6

13 2 Medical Emergencies in Dental Practice Each dental practice must stock a core list of drugs and equipment for use in medical emergencies. All general dental practitioners and dental care professionals are required to ensure that they are competent in the use of both the drugs and the equipment and are able to recognise medical emergencies 3,4. The SDCEP Practice Support Manual 5 ( contains further information on emergency medical equipment and storage of emergency drugs. Brief details of the drugs used in the management of medical emergencies are provided here. Refer to guidance from the Resuscitation Council (UK) 3 for more-detailed advice on how to recognise, assess and manage medical emergencies and for details of the equipment and training required to be able to deal with medical emergencies and resuscitation effectively. It is important to undertake regular training in the management of medical emergencies within the dental environment to keep up to date with current guidance. Training in medical emergencies is a core element of continuing professional development (CPD) for dentists and all dental care professionals. The current recommended drugs for medical emergencies are: Adrenaline, 1-ml ampoules of 1:1000 solution for intramuscular (i.m.) injection Aspirin, 300 mg dispersible tablets Glucagon, for i.m. injection of 1 mg Glyceryl trinitrate (GTN) spray, 400 μg per metered dose Midazolam buccal liquid, 10 mg/ml, or midazolam injection (as hydrochloride) 5 mg/ml 2-ml ampoules, for topical buccal administrationψ Oral glucose (there are several alternative forms, including non-diet fizzy drinks, glucose gel, powdered glucose and sugar lumps) Oxygen cylinder, two size D or two size CD or one size E Salbutamol inhaler, 100 μg per actuation Although the above list includes midazolam for topical administration, parenteral midazolam is a suitable alternative for use by appropriately trained individuals. Ensure the supply of oxygen contained in the cylinders will enable adequate flow rates (10 litres/minute) to be maintained until the arrival of the ambulance or the patient recovers fully. A full size D cylinder contains nominally 340 litres of oxygen and therefore should provide oxygen for up to ~30 minutes; a full size CD cylinder contains nominally 460 litres of oxygen and therefore should provide oxygen for up to ~45 minutes; a full size E cylinder contains nominally 680 litres of oxygen and therefore should provide oxygen for up to ~60 minutes. 7

14 2 Medical Emergencies in Dental Practice Note that the British National Formulary, Volume 61 (BNF 61) 1 continues to recommend buccal midazolam as an emergency drug for the management of status epilepticus in dental practice. Midazolam is a Schedule 3 controlled drug (CD). This means that: prescriptions or requisitions for midazolam must comply with the full CD regulations; records of midazolam usage do not need to be kept in a CD register; invoices for midazolam need to be retained for 2 years; midazolam (as other Schedule 3 drugs) should be denatured before being placed in waste containers; see SDCEP Practice Support Manual 5 ( for guidance on the denaturation of midazolam; midazolam is exempt from the safe custody requirements and will not legally require storage in a CD cabinet; 1 BNF 61 includes the CD symbol against midazolam preparations. Information on the legal status of midazolam is also shown in the section Controlled Drugs and Drug Dependence in general BNF guidance. In addition, dental practices might wish to stock the following to aid the management of patients with mild allergic reactions: Cetirizine 10 mg tablets or oral solution (5 mg/5 ml) Chlorphenamine, 4 mg tablets or oral solution (2 mg/5 ml) Loratadine, 10 mg tablets Use these drugs in the following emergencies in the order stated. 8

15 2 Medical Emergencies in Dental Practice 2.1 Anaphylaxis Key signs of anaphylaxis: Marked upper airway (laryngeal) oedema and bronchospasm, causing stridor and wheezing Tachycardia (heart rate > 110 per minute) Symptoms include: Abdominal pain, vomiting, diarrhoea, and a sense of impending doom Flushing, but pallor might also occur Patients may also display symptoms of mild allergy (see section 2.2) Management The priority is to transfer the patient to hospital as an emergency. Assess the patient. Call for an ambulance. Secure the patient s airway and help to restore their blood pressure by laying the patient flat and raising their feet. Administer 100% oxygen flow rate: 10 litres/minute. As for adults Administer adrenaline, 0.5 ml (1:1000), i.m. injection repeated after 5 minutes if needed 7. Adrenaline (1:1000) 7 6 months 6 years 0.15 ml 6 12 years 0.3 ml years 0.5 ml Use 0.3 ml adrenaline for children aged years if the child is small or prepubertal. If cardiac arrest follows an anaphylactic reaction, start basic life support (BLS) immediately. [Refer to Resuscitation Council (UK) guidance 3 for details of BLS for adults and children.] 9

16 2 Medical Emergencies in Dental Practice 2.2 Treatment of Milder Forms of Allergy Key signs of mild allergy: Urticaria and rash, particularly of chest, hands and feet Rhinitis, conjunctivitis Mild bronchospasm without evidence of severe shortness of breath Management Administer 1 Cetirizine Tablet, 10 mg. Cetirizine Tablet, 10 mg or Oral Solution, 5mg/5 ml 6-12 years 5 mg years As for adults NB: Although drowsiness is rare, advise patients not to drive. Use with caution in patients with hepatic impairment or epilepsy. Cetirizine tablets are not licensed for use in children under 6 years (see section 1.2), except for use in children aged 2 6 years for treatment of seasonal allergic rhinitis. or Administer 1 Chlorphenamine Tablet, 4 mg. Chlorphenamine Tablet, 4 mg or Oral Solution, 2 mg/5 ml 2 6 years 1 mg 6 12 years 2 mg years 4 mg NB: Chlorphenamine can cause drowsiness. Advise patients not to drive. Use with caution in patients with hepatic impairment, prostatic hypertrophy, epilepsy, urinary retention, glaucoma or pyloroduodenal obstruction. Avoid use in children with severe liver disease. Do not give to children under 2 years, except on specialist advice, because the safety of the use of chlorphenamine has not been established. Chlorphenamine tablets are not licensed for use in children under 6 years (see section 1.2). Chlorphenamine oral solution (syrup) is not licensed for use in children under 1 year (see Section 1.2). or 10

17 2 Medical Emergencies in Dental Practice Administer 1 Loratadine Tablet, 10 mg. Loratadine Tablet, 10 mg years As for adults NB: Although drowsiness is rare advise patients not to drive. Use with caution in patients with hepatic impairment or epilepsy. If the patient displays signs of mild bronchospasm: Administer a salbutamol inhaler, 4 puffs (100 µg per actuation), through a large-volume spacer, repeat as needed. Salbutamol inhaler years 1 puff via a spacer every 15 seconds (max. 10 puffs), repeat above regime at minute intervals as needed. Refer the patient to their general medical practitioner. Treatment with antihistamines is only suitable in cases of mild allergy; severe allergic reactions must be treated as stated in section

18 2 Medical Emergencies in Dental Practice 2.3 Asthma Key signs of life-threatening asthma Cyanosis or respiratory rate <8 per minute Bradycardia (heart rate <50 per minute) Exhaustion, confusion, decreased conscious level Key signs of acute severe asthma Inability to complete sentences in one breath Respiratory rate >25 per minute Tachycardia (heart rate >110 per minute) Management The priority is to transfer a patient displaying symptoms of life-threatening asthma to hospital immediately as an emergency. Assess the patient. Sit patient upright. Administer 100% oxygen flow rate: 10 litres/minute. As for adults Administer the patient s own bronchodilator (2 puffs); if unavailable, administer a salbutamol inhaler, 4 puffs (100 µg per actuation), through a large-volume spacer, repeat as needed. Salbutamol inhaler 2-18 years 1 puff via a spacer every 15 seconds (max. 10 puffs), repeat above regime at minute intervals as needed. If a patient suffering from a severe episode of asthma does not respond to treatment with bronchodilators within 5 minutes of administration, they should also be transferred to hospital as an emergency. 12

19 2 Medical Emergencies in Dental Practice 2.4 Cardiac Emergencies Acute Coronary Syndromes (Angina and Myocardial Infarction) Key sign: Progressive onset of severe, crushing pain in the centre and across the front of chest; the pain might radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back Symptoms include: Shortness of breath Increased respiratory rate Skin becomes pale and clammy Nausea and vomiting are common Pulse might be weak and blood pressure might fall Management Assess the patient. Administer 100% oxygen flow rate: 10 litres/minute. Not relevant for children Administer glyceryl trinitrate (GTN) spray, 2 puffs (400 µg per metered dose) sublingually, repeated after 3 minutes if chest pain remains. Not relevant for children If the patient does not respond to GTN treatment then the priority is to transfer the patient to hospital as an emergency. Call for an ambulance. 13

20 2 Medical Emergencies in Dental Practice Administer aspirin, 300 mg dispersible tablet, orally. Do not use in children because, rarely, it can cause Reye s syndrome NB: The aspirin tablet should be chewed or dispersed in water. If aspirin is given, send a note with the patient to inform the hospital staff. Aspirin is not licensed for use in children under 16 years (see Section 1.2). If the patient becomes unresponsive, check for signs of life (breathing and circulation), and if there are no signs of life or no normal breathing, initiate basic life support (BLS) and carry out early defibrillation if a defibrillator is available. [Refer to Resuscitation Council (UK) guidance 3 for details of BLS for adults and children.] Cardiac Arrest Key signs: Loss of consciousness Absence of breathing Loss of pulse Dilation of pupils Management The priority is to transfer the patient to hospital as an emergency. Call for an ambulance. Initiate BLS, using 100% oxygen or ventilation flow rate: 10 litres/minute. As for adults, with minor modifications to BLS for children Refer to Resuscitation Council (UK) guidance 3 for details of BLS for adults and children. If a defibrillator is available, carry out early defibrillation. 14

21 2 Medical Emergencies in Dental Practice 2.5 Epilepsy Key signs: Symptoms include: Sudden loss of consciousness, patient may become rigid, fall, might give a cry and becomes cyanosed (tonic phase) Jerking movements of the limbs; the tongue might be bitten (clonic phase) Brief warning or aura Frothing from the mouth and urinary incontinence NB: Fitting might be associated with other conditions (e.g. hypoglycaemia, fainting). Management Assess the patient. Do not try to restrain convulsive movements. Ensure the patient is not at risk from injury. Secure the patient s airway. Administer 100% oxygen flow rate: 10 litres/minute. As for adults The seizure will typically last a few minutes; the patient might then become floppy but remain unconscious. Once the patient regains consciousness they may remain confused. However, if the epileptic fit is repeated or prolonged (5 minutes or longer), continue administering oxygen and: 15

22 2 Medical Emergencies in Dental Practice Administer 10 mg midazolam topically into the buccal cavity. Use either buccal liquid (10 mg/ml) or injection solution (5 mg/ml) Midazolam buccal liquid (10 mg/ ml) or injection solution (5 mg/ml) 6 months - 1 year 2.5 mg 1-5 years 5 mg 5-10 years 7.5 mg years 10 mg 2 mg/ml solution is also available but the 5 mg/ml injection solution is preferred because of the smaller volume required. Midazolam buccal liquid and midazolam injection solution are not licensed for use in status epilepticus (see Section 1.2). After convulsive movements have subsided, place the patient in the recovery position and check the airway. Do not send the patient home until they have recovered fully. Only give medication if convulsive seizures are prolonged (last for 5 minutes or longer) or recur in quick succession. In these cases and if this was the first episode of epilepsy for the patient, the convulsion was atypical, injury occurred or there is difficulty monitoring the patient, call for an ambulance. 16

23 2 Medical Emergencies in Dental Practice 2.6 Faint Key signs: Patient feels faint, dizzy, light-headed Slow pulse rate Loss of consciousness Symptoms include: Pallor and sweating Nausea and vomiting Management Assess the patient. Lay the patient flat and, if the patient is not breathless, raise the patient s feet. Loosen any tight clothing around the neck. Administer 100% oxygen flow rate: 10 litres/minute until consciousness is regained. As for adults 17

24 2 Medical Emergencies in Dental Practice 2.7 Hypoglycaemia Key signs: Aggression and confusion Sweating Tachycardia (heart rate >110 per min) Symptoms include: Shaking and trembling Difficulty in concentration/vagueness Slurring of speech Headache Fitting Unconsciousness Management Assess the patient. Administer 100% oxygen flow rate: 10 litres/minute. As for adults If the patient remains conscious and cooperative: Administer oral glucose (10 20 g), repeated, if necessary, after minutes. As for adults 18

25 2 Medical Emergencies in Dental Practice If the patient is unconscious or uncooperative: Administer glucagon, 1 mg, i.m. injection. Glucagon, i.m. injection 2-18 years 0.5 mg body-weight <25 kg 2-18 years 1 mg body-weight >25 kg and Administer oral glucose (10 20 g) when the patient regains consciousness. As for adults If the patient does not respond or any difficulty is experienced, call for an ambulance. 19

26 2 Medical Emergencies in Dental Practice 2.8 Other Medical Emergencies Stroke Key signs: Facial weakness; one eye may droop or patient may only be able to move one side of mouth Arm weakness Communication problems; slurred speech; patient is unable to understand what is being said to them Management The priority is to transfer the patient to hospital as an emergency Assess the patient. Administer 100% oxygen flow rate: 10 litres/minute. As for adults If the patient is unconscious, secure their airway and place in the recovery position. Call for an ambulance. 20

27 2 Medical Emergencies in Dental Practice Aspiration and Choking Dental patients are susceptible to choking and aspiration due to the presence of blood and secretions in their mouths for prolonged periods, suppressed pharyngeal reflexes due to local anaesthesia or the presence of impression material or dental equipment in their mouths. Signs and symptoms include: Patient may cough and splutter Patient may complain of breathing difficulty Breathing may become noisy on inspiration (stridor) Patient may develop paradoxical chest or abdominal movements Patient may become cyanosed and lose consciousness Management Aspiration Encourage patient to cough vigorously. Administer 100% oxygen flow rate: 10 litres/minute. As for adults Administer a salbutamol inhaler, 4 puffs (100 µg per actuation), through a large-volume spacer, repeat as needed. Salbutamol inhaler 2-18 years 1 puff via a spacer every 15 seconds (max. 10 puffs), repeat above regime at minute intervals as needed. 21

28 2 Medical Emergencies in Dental Practice If you suspect that a large fragment has been inhaled or swallowed but there are no signs or symptoms, refer the patient to hospital for x-ray and removal of the fragment if necessary. If the patient is symptomatic following aspiration, refer them to hospital as an emergency. Choking Remove any visible foreign bodies in the mouth and pharynx. Encourage the patient to cough. If the patient is unable to cough but remains conscious, commence back blows followed by abdominal thrusts. If the patient becomes unconscious, basic life support (BLS) should be started immediately; this may also help to dislodge the foreign body. Call an ambulance and transfer patient to hospital as an emergency. 22

29 3 Anxiety An oral dose of a benzodiazepine may be used for premedication to aid anxiety management before dental treatment. However, note that benzodiazepines are addictive and susceptible to abuse and therefore only the minimum number of tablets required should be prescribed. Advise the patient that they will require an escort and that they should not drive. Note that such premedication is not a definitive sedation technique. Guidance on the provision of conscious sedation in dentistry is the subject of separate Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance 8. Refer to SDCEP guidance Conscious Sedation in Dentistry 8 before providing conscious sedation. An appropriate regimen to aid anxiety management is: Diazepam Tablets, 5 mg Send: 1 tablet Label: 1 tablet 2 hours before procedure Not recommended because it has an unpredictable effect in children NB: The dose of diazepam can be increased to 10 mg if necessary. Halve the adult dose for elderly or debilitated patients. Advise all patients that they will require an escort and that they should not drive. 23

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31 4 Bacterial Infections Prolonged courses of antibiotic treatment can encourage the development of drug resistance and therefore the prescribing of antibiotics must be kept to a minimum and used only when there is a clear need. The use of broad-spectrum antibiotics has also been associated with the rise in Clostridium difficile - associated disease observed in both primary and secondary care. Care should therefore be taken when prescribing these antibiotics to vulnerable groups, such as the elderly and those with a history of gastrointestinal disease, including those using proton pump inhibitor (PPI) drugs for dyspepsia and gastro-oesophageal reflux diseases. As a first step in the treatment of bacterial infections, use local measures. For example, drain pus if present in dental abscesses by extraction of the tooth or through the root canals, and attempt to drain any soft-tissue pus by incision. Antibiotics are appropriate for oral infections where there is evidence of spreading infection (cellulitis, lymph node involvement, swelling) or systemic involvement (fever, malaise). In addition, other indications for antibiotics are acute necrotising ulcerative gingivitis and sinusitis, and pericoronitis where there is systemic involvement or persistent swelling despite local treatment. Use antibiotics in conjunction with, and not as an alternative to, local measures. Where there is significant trismus, floor-of-mouth swelling or difficulty breathing, transfer patients to hospital as an emergency. There is no evidence to support the prescription of antibiotics for the treatment of pulpitis or the prevention of dry socket in non-immunocompromised patients undergoing non-surgical dental extractions. Until recently, some broad-spectrum antibiotics were thought to reduce the efficacy of combined oral contraceptives and contraceptive patches or rings. However the recommendations of the Faculty of Sexual and Reproductive Healthcare Clinical Guidance: Drug Interactions with Hormonal Contraception 9 state that additional contraceptive precautions are no longer necessary when antibacterials that do not induce liver enzymes are taken with combined oral contraceptives, unless diarrhoea or vomiting occurs. Also, no additional contraceptive precautions are required when contraceptive patches or vaginal rings are used with antibacterials that do not induce liver enzymes. These updated recommendations are reflected in BNF Before prescribing antibiotics, refer to the BNF ( and BNFC ( for drug interactions. Advise patients to space out doses as much as possible throughout the day. Review patients who have received a course of antibiotic treatment. 25

32 4 Bacterial Infections 4.1 Infective Endocarditis Previously, in dentistry, antibiotics were prescribed as prophylactics for the prevention of infective endocarditis. However, the National Institute for Health and Clinical Excellence (NICE) recommends that antibiotic prophylaxis should not be used in patients undergoing dental procedures 10. This advice is also stated in the BNF (BNF 61 1 ). In addition, there is no evidence that prophylaxis is of any benefit in patients with prosthetic joints and it is unacceptable to expose patients to the potential adverse effects of antibiotics in these circumstances. 4.2 Dental Abscess Dental abscesses are usually infected with viridans Streptococcus spp. or Gram-negative organisms. Treat dental abscesses in the first instance by using local measures to achieve drainage, with removal of the cause where possible (see below). Antibiotics are required only in cases of spreading infection (cellulitis, lymph node involvement, swelling) or systemic involvement (fever, malaise). Amoxicillin is usually effective at treating such infections, and is as effective as phenoxymethylpenicillin (penicillin V) but is better absorbed. The duration of treatment depends on the severity of the infection and the clinical response, but drugs are usually given for 5 days. However, do not prolong courses of treatment unduly because this can encourage the development of resistance. For severe infections the dose of amoxicillin and phenoxymethylpenicillin should be doubled. Severe infections include those cases where there is extra-oral swelling, eye closing or trismus but it is a matter of clinical judgement. Where there is significant trismus, floor-of-mouth swelling or difficulty breathing, transfer patients to hospital as an emergency. If the patient does not respond to the prescribed antibiotic, check the diagnosis and consider referral to a specialist. Dental abscesses should be treated with local measures in the first instance. Local Measures to be used in the first instance If pus is present in a dental abscess, drain by extraction of the tooth or through the root canals. If pus is present in any soft tissue, attempt to drain by incision. If local measures have proved ineffective or there is evidence of cellulitis, spreading infection or systemic involvement, one of the following first-line antibiotics can be prescribed. The antibiotic doses recommended in this guidance are based on the doses recommended by the BNF. However dentists should be aware that local formulary recommendations may differ. 26

33 4 Bacterial Infections An appropriate 5-day regimen is a choice of: Amoxicillin Capsules, 250 mg Send: 15 capsules Label: 1 capsule three times daily Amoxicillin Capsules, 250 mg, or Oral Suspension*, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year 62.5mg three times daily 1-5 years 125 mg three times daily 5-18 years 250 mg three times daily NB: The dose of amoxicillin should be doubled in severe infection in adults and children. Amoxicillin, like other penicillins, can result in hypersensitivity reactions, including rashes and anaphylaxis, and can cause diarrhoea. Do not prescribe amoxicillin to patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration as these individuals are at risk of immediate hypersensitivity. *Sugar-free preparation is available. or Phenoxymethylpenicillin Tablets, 250 mg Send: 40 tablets Label: 2 tablets four times daily Phenoxymethylpenicillin Tablets, 250 mg, or Oral Solution, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year 62.5 mg four times daily 1-6 years 125 mg four times daily 6-12 years 250 mg four times daily years 500 mg four times daily NB: For severe infection in adults, the dose of phenoxymethylpenicillin should be doubled. For severe infection in children up to 12 years, increase dose up to 12.5 mg/kg four times daily. For severe infection in children aged years increase dose up to 1 g four times daily. Phenoxymethylpenicillin, like other penicillins, can result in hypersensitivity reactions, including rashes and anaphylaxis, and can cause diarrhoea. Do not prescribe phenoxymethylpenicillin to patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration as these individuals are at risk of immediate hypersensitivity. 27

34 4 Bacterial Infections Metronidazole is a suitable alternative for the management of dental abscess in patients who are allergic to penicillin. It can also be used as an adjunct to amoxicillin in patients with spreading infection or pyrexia. (NB: Both drugs are used in the same doses as when administered alone.) In patients who are allergic to penicillin, an appropriate 5-day regimen is: Metronidazole Tablets, 200 mg Send: 15 tablets Label: 1 tablet three times daily Metronidazole Tablets, 200 mg, or Oral Suspension, 200 mg/5 ml 1-3 years 50 mg three times daily 3-7 years 100 mg twice daily 7-10 years 100 mg three times daily years 200 mg three times daily NB: Advise patient to avoid alcohol (metronidazole has a disulfiram-like reaction with alcohol). The anticoagulant effect of warfarin might be enhanced by metronidazole. Metronidazole is not licensed for use in children under 1 year (see Section 1.2). Erythromycin is another alternative to the penicillins but causes nausea, vomiting and diarrhoea in some patients, and many organisms are resistant to erythromycin. In patients who are allergic to penicillin, an appropriate 5-day regimen is: Erythromycin Tablets, 250 mg Send: 20 tablets Label: 1 tablet four times daily Erythromycin Tablets, 250 mg, or Oral Suspension*, 125 mg/5 ml 6 months - 2 years 125 mg four times daily 2-18 years 250 mg four times daily NB: The dose of erythromycin can be doubled in severe infection in adults and children. Erythromycin can cause nausea, vomiting and diarrhoea in some patients, and the anticoagulant effect of warfarin might be enhanced by erythromycin. Do not prescribe to patients taking statins. *Sugar-free preparation is available. 28

35 4 Bacterial Infections Second-line antibiotics for dental abscess The empirical use of other antibiotics such as clindamycin, co-amoxiclav and clarithromycin offers no advantage over amoxicillin, phenoxymethylpenicillin, metronidazole and erythromycin for most dental patients. Their routine use in dentistry is unnecessary and could contribute to the development of antimicrobial resistance. Also the use of broad-spectrum antibiotics is associated with the increase in Clostridium difficile infection observed in both primary and secondary care. However, if a patient has not responded to the first-line antibiotic prescribed, check the diagnosis and either refer the patient or consider speaking to a specialist before prescribing clindamycin, co-amoxiclav or clarithromycin. Clindamycin is active against Gram-positive cocci, including streptococci and penicillin-resistant staphylococci, and can be used if the patient has not responded to amoxicillin or metronidazole. It should be noted, however, that clindamycin can cause the serious adverse effect of antibiotic-associated colitis more frequently than other antibiotics. Co-amoxiclav is active against beta-lactamase-producing bacteria that are resistant to amoxicillin, and can be used to treat severe dental infection with spreading cellulitis or dental infection that has not responded to first-line antibacterial treatment. Clarithromycin is slightly more active against beta-lactamase-producing bacteria than erythromycin. As the use of broad-spectrum antibiotics, especially co-amoxiclav and clindamycin, can result in Clostridium difficile infection, use of these drugs should be restricted to second-line treatment of severe infections only. If patients do not respond to first-line amoxicillin or metronidazole treatment, or in cases of severe infection with spreading cellulitis, an appropriate 5-day regimen is: Clindamycin Capsules, 150 mg Send: 20 capsules Label: 1 capsule four times daily, swallowed with water years As for adults NB: Advise patient that capsule should be swallowed with a glass of water. Do not prescribe clindamycin to patients with diarrhoeal states. Advise patient to discontinue use immediately if diarrhoea or colitis develops as clindamycin can cause the side-effect of antibiotic-associated colitis. or 29

36 4 Bacterial Infections Co-amoxiclav 250/125 Tablets Send: 15 tablets Label: 1 tablet three times daily years As for adults NB: Co-amoxiclav 250/125 tablets are amoxicillin 250 mg as trihydrate and clavulanic acid 125 mg as potassium salt. Cholestatic jaundice can occur either during or shortly after the use of co-amoxiclav; this condition is more common in patients above the age of 65 years and in men. Do not prescribe co-amoxiclav to patients who have a history of co-amoxiclav-associated or penicillin-associated jaundice or hepatic dysfunction. Co-amoxiclav, like other penicillins, can result in hypersensitivity reactions, including rashes and anaphylaxis, and can cause diarrhoea. Do not prescribe co-amoxiclav to patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration as these individuals are at risk of immediate hypersensitivity. An appropriate 7-day regimen is: or Clarithromycin Tablets, 250 mg Send: 14 tablets Label: 1 tablet two times daily Clarithromycin Tablets, 250 mg or Oral Suspension 125 mg/5ml or 250 mg/5 ml 1-5 years 125 mg two Body weight times daily kg 5-12 years mg two Body weight times daily kg years 250 mg two times daily NB: Use with caution in patients who are predisposed to QT interval prolongation including electrolyte disturbances and those with hepatic impairment or renal impairment. Do not prescribe for pregnant women or nursing mothers. Do not prescribe to patients taking statins. Refer to appendix 1 of the BNF for drug interactions (macrolides). 30

37 4 Bacterial Infections 4.3 Acute Necrotising Ulcerative Gingivitis and Pericoronitis As an adjunct to local measures (see below), metronidazole is the drug of first choice in the treatment of acute necrotising ulcerative gingivitis and the treatment of pericoronitis where there is systemic involvement or persistent swelling despite local measures. A suitable alternative is amoxicillin. Local Measures to be used in the first instance In the case of acute necrotising ulcerative gingivitis, carry out scaling and provide oral hygiene advice. In the case of pericoronitis, carry out irrigation and debridement. If drug treatment is required, an appropriate 3-day regimen is: Metronidazole Tablets, 200 mg Send: 9 tablets Label: 1 tablet three times daily Metronidazole Tablets, 200 mg, or Oral Suspension, 200 mg/5 ml 1-3 years 50 mg three times daily 3-7 years 100 mg twice daily 7-10 years 100 mg three times daily years 200 mg three times daily NB: Advise patient to avoid alcohol (metronidazole has a disulfiram-like reaction with alcohol). The anticoagulant effect of warfarin might be enhanced by metronidazole. Metronidazole is not licensed for use in children under 1 year (see Section 1.2). or 31

38 4 Bacterial Infections Amoxicillin Capsules, 250 mg Send: 9 capsules Label: 1 capsule three times daily Amoxicillin Capsules, 250 mg, or Oral Suspension*, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year 62.5mg three times daily 1-5 years 125 mg three times daily 5-18 years 250 mg three times daily NB: The dose of amoxicillin should be doubled in severe infection in adults and children. Amoxicillin, like other penicillins, can result in hypersensitivity reactions, including rashes and anaphylaxis, and can cause diarrhoea. Do not prescribe amoxicillin to patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration as these individuals are at risk of immediate hypersensitivity. *Sugar-free preparation is available. 4.4 Sinusitis Sinusitis is a generally self-limiting condition that has an average duration of 2½ weeks. Therefore, in suspected cases of sinusitis local measures should be advised in the first instance. Antibiotic therapy should only be used for persistent symptoms and/or purulent discharge lasting at least seven days or if symptoms are severe. Local Measures to be used in the first instance Advise the patient to use steam inhalation not recommended for children. 32

39 4 Bacterial Infections If drug treatment is required, an appropriate regimen is: Ephedrine Nasal Drops, 0.5% Send: 10 ml Label: 1 drop into each nostril up to three times daily when required Ephedrine Nasal Drops, 0.5% years As for adults NB: Advise patient to use for a maximum of 7 days. In adults and children over 12 years, the dose of ephedrine nasal drops can be increased to 2 drops 3 or 4 times daily, if required. Do not use in patients with high blood pressure. Not licensed for use in children under 12 years (see section 1.2). If an antibiotic is required, an appropriate 7-day regimen is a choice of: Amoxicillin Capsules, 250 mg Send: 21 capsules Label: 1 capsule three times daily Amoxicillin Capsules, 250 mg, or Oral Suspension*, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year 62.5mg three times daily 1-5 years 125 mg three times daily 5-18 years 250 mg three times daily NB: The dose of amoxicillin should be doubled in severe infection in adults and children. Amoxicillin, like other penicillins, can result in hypersensitivity reactions, including rashes and anaphylaxis, and can cause diarrhoea. Do not prescribe amoxicillin to patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration as these individuals are at risk of immediate hypersensitivity. *Sugar-free preparation is available. or 33

40 4 Bacterial Infections Doxycycline Capsules, 100 mg Send: 8 capsules Label: 2 capsules on the first day, followed by 1 capsule daily Doxycyline Capsules, 100 mg <12 years Not recommended for use because it causes intrinsic staining of developing teeth 12 years As for adults NB: Advise patient to swallow capsules whole with plenty of fluid during meals, while sitting or standing. For severe infection in adults and children aged 12 years and over, 2 capsules daily can be given. Use with caution in patients with hepatic impairment or those receiving potentially hepatotoxic drugs. Do not prescribe for pregnant women, nursing mothers or children under 12 years, as it can deposit on growing bone and teeth (by binding to calcium) and cause staining and, occasionally, dental hypoplasia. Doxycycline can cause nausea, vomiting, diarrhoea, dysphagia, oesophageal irritation and photosensitivity. The anticoagulant effect of warfarin might be enhanced by doxycycline. Doxycycline is also available as doxycyline dispersible tablets. Doxycycline is not licensed for use in children under 12 years (see Section 1.2). 34

41 5 Fungal Infections Superficial fungal infections can be treated in a primary care setting. However, chronic hyperplastic candidosis (candidal leukoplakia) is potentially premalignant and therefore refer patients with this condition for specialist treatment. Treatment with a topical antifungal agent, such as nystatin, is effective against superficial infections but compliance is poor because of its unpleasant taste. Thus, miconazole or the systemically absorbed drug fluconazole are preferred unless contraindicated. Note that fluconazole interacts with many drugs, including warfarin and statins, and therefore do not give fluconazole to patients taking these drugs. In addition, avoid the use of miconazole, a topical azole antifungal agent, in such patients because sufficient drug is absorbed to cause similar interactions. 5.1 Pseudomembranous Candidosis and Erythematous Candidosis Several patient groups are predisposed to pseudomembranous candidosis and erythematous candidosis infections (e.g. patients taking inhaled corticosteroids, cytotoxics or broad-spectrum antibacterials, diabetic patients, patients with nutritional deficiencies, or patients with serious systemic disease associated with reduced immunity such as leukaemia, other malignancies and HIV infection). If the patient does not respond to appropriate local measures and a course of drug treatment, or there is no identifiable cause, refer the patient to a specialist or the patient s general medical practitioner for further investigation. Fungal infections in immunocompromised patients with serious systemic disease are likely to need intravenous systemic treatment; therefore, refer such patients to a specialist or the patient s general medical practitioner. When these infections are associated with the use of inhaled corticosteroids for lung disease, use local measures in the first instance to try to avoid the problem. Local Measures - to be used in the first instance Advise patients who use a corticosteroid inhaler to rinse their mouth with water or brush their teeth immediately after using the inhaler. 35

42 5 Fungal Infections If drug treatment is required, an appropriate 7-day regimen is a choice of: Fluconazole Capsules, 50 mg Send: 7 capsules Label: 1 capsule daily Fluconazole Capsules 50 mg or Oral Suspension, 50 mg/5 ml 6 months - 12 years 3-6 mg/kg on first day and then 3 mg/kg (max. 50 mg) daily years 50 mg daily NB: Fluconazole can be administered for a maximum of 14 days for the treatment of oropharyngeal candidosis. Do not prescribe fluconazole for patients taking warfarin or statins. or Miconazole Oromucosal Gel*, 24 mg/ml Send: 80 g tube Label: Apply a pea-sized amount after food four times daily Miconazole Oromucosal Gel*, 24 mg/ml 2-6 years Apply a pea-sized amount twice daily after food 6-18 years Apply a pea sized amount four times daily after food NB: Advise patient to continue use for 48 hours after lesions have healed. Do not prescribe miconazole for patients taking warfarin or statins. *Sugar-free preparation is available. 36

43 5 Fungal Infections If fluconazole and miconazole are contraindicated, an appropriate regimen is: Nystatin Oral Suspension, 100,000 units/ml Send: 30 ml Label: 1 ml after food four times daily for 7 days As for adults NB: Advise patient to rinse suspension around mouth and then retain suspension near lesion for 5 minutes before swallowing. Advise patient to continue use for 48 hours after lesions have healed. 5.2 Denture Stomatitis Denture stomatitis can be treated effectively by local measures (see below). However, antifungal agents can be used as an adjunct to these local measures, particularly to reduce palatal inflammation before taking impressions for new dentures. Chlorhexidine mouthwash is also effective against fungal infections. Local Measures to be used in the first instance Advise the patient to: brush the palate daily to treat the condition; clean their dentures thoroughly (by soaking in chlorhexidine mouthwash or sodium hypochlorite for 15 minutes twice daily; note that hypochlorite should only be used for acrylic dentures); leave their dentures out as often as possible during the treatment period. If dentures themselves are identified as contributing to the problem, ensure the dentures are adjusted or new dentures are made to avoid the problem recurring. 37

44 5 Fungal Infections If drug treatment is required, an appropriate 7-day regimen is a choice of: Fluconazole Capsules, 50 mg Send: 7 capsules Label: 1 capsule daily Fluconazole Capsules 50 mg or Oral Suspension, 50 mg/5 ml 6 months - 12 years 3-6 mg/kg on first day and then 3 mg/kg (max. 50 mg) daily years 50 mg daily NB: Fluconazole can be administered for a maximum of 14 days for the treatment of denture stomatitis. Do not prescribe fluconazole for patients taking warfarin or statins. or Miconazole Oromucosal Gel*, 24 mg/ml Send: 80 g tube Label: Apply a pea-sized amount to fitting surface of upper denture after food four times daily Miconazole Oromucosal Gel*, 24 mg/ml 2-6 years Apply a pea-sized amount to fitting surface of upper denture twice daily after food 6-18 years As for adults NB: Advise patient to remove upper denture, apply gel sparingly to fitting surface and then reinsert. Advise patient to continue use for 48 hours after lesions have healed. Do not prescribe miconazole for patients taking warfarin or statins. *Sugar-free preparation is available. 38

45 5 Fungal Infections If fluconazole and miconazole are contraindicated, an appropriate regimen is: Nystatin Oral Suspension, 100,000 units/ml Send: 30 ml Label: 1 ml after food four times daily for 7 days As for adults NB: Advise patient to remove dentures before using drug, rinse suspension around mouth and then retain suspension near lesion for 5 minutes before swallowing. Advise patient to continue use for 48 hours after lesions have healed. 5.3 Angular Cheilitis Angular cheilitis in denture-wearing patients is usually caused by infection with Candida spp. and there is an associated denture stomatitis that should be treated concurrently. In those without dentures, angular cheilitis is more likely to be caused by infection with Streptococcus spp. or Staphylococcus spp. Miconazole cream is effective against both Candida and Gram-positive cocci and is therefore appropriate to use for all patients. Where the condition is clearly fungal in nature nystatin ointment can be used and where it is bacterial in nature sodium fusidate (fusidic acid) ointment can be used. Note that creams are normally used on wet surfaces whereas ointments are normally used on dry surfaces. Unresponsive cases can be treated with miconazole and hydrocortisone cream or ointment. Continue treatment until clinical resolution is achieved. A lack of clinical response might indicate predisposing factors such as a concurrent haematinic deficiency or diabetes. Refer such cases to a specialist or the patient s general medical practitioner. If dentures themselves are identified as contributing to the problem, ensure the dentures are adjusted or new dentures are made to avoid the problem recurring. 39

46 5 Fungal Infections An appropriate regimen is a choice of: Miconazole Cream, 2% Send: 20 g tube Label: Apply to angles of mouth twice daily As for adults NB: Advise patient to continue use for 10 days after lesions have healed. or Sodium Fusidate Ointment, 2% Send: 15 g tube Label: Apply to angles of mouth four times daily As for adults NB: To avoid the development of resistance, do not prescribe sodium fusidate for longer than 10 days. An appropriate regimen for unresponsive cases is a choice of: Miconazole (2%) and Hydrocortisone (1%) Cream Send: 30 g tube Label: Apply to angles of mouth twice daily As for adults NB: Advise patient to continue use for a maximum of 7 days. or Miconazole (2%) and Hydrocortisone (1%) Ointment Send: 30 g tube Label: Apply to angles of mouth twice daily As for adults NB: Advise patient to continue use for a maximum of 7 days. 40

47 6 Viral Infections 6.1 Herpes Simplex Infections Primary herpetic gingivostomatitis [as a result of herpes simplex virus (HSV)] is best managed by symptomatic relief [i.e. nutritious diet, plenty of fluids, bed rest, use of analgesics and antimicrobial mouthwashes (either chlorhexidine or hydrogen peroxide )]. The use of antimicrobial mouthwashes controls plaque accumulation if toothbrushing is painful and also helps to control secondary infection in general. Treat infections in immunocompromised patients and severe infections in nonimmunocompromised patients with a systemic antiviral agent, the drug of choice being aciclovir. Give patients analgesics regularly to minimise oral discomfort; a topical benzydamine hydrochloride (oromucosal) spray might provide additional relief from oral discomfort and is particularly helpful in children. Refer immunocompromised patients (both adults and children) with severe infection to hospital. Mild infection of the lips [herpes labialis (cold sores)] in non-immuncompromised patients is treated with a topical antiviral drug (aciclovir cream or penciclovir cream). Bell s palsy is sometimes associated with herpes simplex. Refer patients with Bell s palsy to a specialist or the patient s general medical practitioner for treatment. Local Measures to be used in the first instance Advise the patient to avoid dehydration and alter their diet (to include soft food and adequate fluids) and use analgesics and an antimicrobial mouthwash. 41

48 6 Viral Infections An appropriate mouthwash is a choice of: Chlorhexidine Mouthwash, 0.2% Send: 300 ml Label: Rinse mouth for 1 minute with 10 ml twice daily As for adults NB: Advise patient to spit out mouthwash after rinsing and use until lesions have resolved and patient can carry out good oral hygiene. Chlorhexidine gluconate might be incompatible with some ingredients in toothpaste; advise patient to leave an interval of at least 30 minutes between using mouthwash and toothpaste. Also advise patient that chlorhexidine mouthwash can be diluted 1:1 with water with no loss in efficacy. or Hydrogen Peroxide Mouthwash, 6% Send: 300 ml Label: Rinse mouth for 2 minutes with 15 ml diluted in half a tumbler of warm water three times daily As for adults NB: Advise patient to spit out mouthwash after rinsing and use until lesions have resolved and patient can carry out good oral hygiene. Hydrogen peroxide mouthwash can be used as a rinse for up to 3 minutes, if required. 42

49 6 Viral Infections For infections in immunocompromised patients and severe infections in nonimmunocompromised patients, an appropriate 5-day regimen is: Aciclovir Tablets, 200 mg Send: 25 tablets Label: 1 tablet five times daily Aciclovir Tablets, 200 mg, or Oral Suspension*, 200 mg/5 ml 6 months - 2 years 100 mg five times daily 2-18 years 200 mg five times daily NB: In both adults and children, the dose can be doubled in immunocompromised patients or if absorption is impaired. *Sugar-free preparation is available. Antiviral creams such as aciclovir and penciclovir can be used to treat herpes labialis in nonimmunocompromised patients. Administer these topical agents at the prodromal stage of a herpes labialis lesion to maximise their benefit. An appropriate regimen is a choice of: Aciclovir Cream, 5% Send: 2 g Label: Apply to lesion every 4 hours (five times daily) for 5 days As for adults NB: Aciclovir cream can be applied for up to 10 days, if required. or Penciclovir Cream, 1% Send: 2 g Label: Apply to lesions every 2 hours during waking for 4 days <12 years Not recommended for use 12 years As for adults Penciclovir is not licensed for use in children under 12 years (see Section 1.2). 43

50 6 Viral Infections 6.2 Varicella-zoster Infections In patients with herpes zoster (shingles), systemic antiviral agents reduce pain, and reduce the incidence of post-herpetic neuralgia and viral shedding. Aciclovir is the drug of choice. However, valaciclovir and famciclovir are suitable alternatives (although they can only be prescribed using a private prescription). Start treatment ideally at diagnosis or within 72 hours of the onset of the rash; even after this point antiviral treatment can reduce the severity of post-herpetic neuralgia. In addition, refer all patients with herpes zoster to a specialist or their general medical practitioner. Refer immunocompromised patients (both adults and children) with herpes zoster to a specialist or the patient s general medical practitioner for treatment. An appropriate 7-day regimen is: Aciclovir Tablets, 800 mg (shingles treatment pack) Send: 35 tablets Label: 1 tablet five times daily Not relevant for children in dental setting Aciclovir tablets and oral suspension are not licensed for the treatment of herpes zoster in children (see Section 1.2). 44

51 7 Odontogenic Pain Most odontogenic pain can be relieved effectively by non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin, which have anti-inflammatory activity. Paracetamol is also effective in the management of odontogenic or post-operative pain but has no demonstrable anti-inflammatory activity. Aspirin is a potent and useful NSAID but avoid its use in children and those with an aspirin allergy, and do not prescribe following a dental extraction or other minor surgery. Pyrexia in children can be managed using paracetamol or ibuprofen. Both drugs can be given alternately to control ongoing pyrexia without exceeding the recommended dose or frequency of administration for either drug. Avoid the use of all NSAIDs in patients with a history of hypersensitivity to aspirin or any other NSAID, including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by aspirin or any other NSAID. All NSAIDs cause gastrointestinal irritation and therefore avoid in patients with previous or active peptic ulcer disease. However, if NSAIDs are required to provide pain relief in these patients, a proton pump inhibitor can be prescribed in conjunction with the NSAID. In addition, use NSAIDs with caution in the elderly, patients with allergic disorders, pregnant women, nursing mothers, those taking oral anticoagulants such as warfarin, those with coagulation defects and those with an inherited bleeding disorder. NSAIDs might impair renal function and so use with caution in patients with renal, cardiac or hepatic impairment. Some patients may already take a daily low-dose of aspirin, in these cases do not prescribe NSAIDs as these can increase the risk of gastro-intestinal side-effects. The NSAID diclofenac is also effective against moderate inflammatory or post-operative pain. The BNF (BNF 61 1 ) does not recommend the use of dihydrocodeine as it is relatively ineffective against dental pain and also causes nausea and constipation. There is also the potential for abuse of dihydrocodeine; therefore, if the drug is to be used, prescribe only the minimum number of tablets required. Prescribe analgesics only as a temporary measure for the relief of pain, and ensure the underlying cause is managed. Base the choice of analgesic on its suitability for the patient. If the following regimens are ineffective, refer the patient to their general medical practitioner. 45

52 7 Odontogenic Pain For mild to moderate odontogenic or post-operative pain, an appropriate 5-day regimen is: Paracetamol Tablets, 500 mg Send: 40 tablets Label: 2 tablets four times daily For children : Paracetamol Tablets or Soluble Tablets, 500 mg, or Oral Suspension*, 120 mg/5 ml or 250 mg/5 ml 6 months 120 mg four times - 2 years daily (max. 4 doses in 24 hours) 2-4 years 180 mg four times daily (max. 4 doses in 24 hours) 4-6 years 240 mg four times daily (max. 4 doses in 24 hours) 6-8 years 250 mg four times daily (max. 4 doses in 24 hours) 8-10 years 375 mg four times daily (max. 4 doses in 24 hours) years 500 mg four times daily (max. 4 doses in 24 hours) NB: Advise patient that paracetamol can be taken at 4-hourly intervals but not to exceed the recommended daily dose (maximum of 4 g for adults). Overdose with paracetamol is dangerous because it can cause hepatic damage that is sometimes not apparent for 4 6 days; as little as g taken within 24 hours can cause severe hepatocellular necrosis. Transfer patients who have taken an overdose to hospital. For more information see the BNF ( Children s doses are in line with the BNFC ( and also reflect more exact paracetamol dosing for children as updated by the MHRA ( in *Sugar-free preparation is available. 46

53 7 Odontogenic Pain For mild to moderate odontogenic, post-operative or inflammatory pain, an appropriate 5-day regimen is: Ibuprofen Tablets, 400 mg Send: 20 tablets Label: 1 tablet four times daily, preferably after food Ibuprofen Oral Suspension*, 100 mg/ 5 ml or Ibuprofen Tablets, 200 mg 6 months 50 mg four times - 1 year daily, preferably after food 1-4 years 100 mg three times daily, preferably after food 4-7 years 150 mg three times daily, preferably after food 7-10 years 200 mg three times daily, preferably after food years 300 mg three times daily, preferably after food years mg four times daily, preferably after food NB: In adults, the dose of ibuprofen can be increased, if necessary, to a maximum of 2.4 g daily. Avoid use in those with a hypersensitivity to aspirin or any other NSAID, including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by aspirin or any other NSAID. Do not prescribe for patients taking a low dose of aspirin daily. Avoid use in patients with previous or active peptic ulcer disease, unless a proton pump inhibitor is co-prescribed (see pg. 49), and use with caution in the elderly, patients with allergic disorders, pregnant women, nursing mothers, those taking oral anticoagulants such as warfarin, those with coagulation defects, those with an inherited bleeding disorder, and those with renal, cardiac or hepatic impairment. *Sugar-free preparation is available. In cases where paracetamol or ibuprofen alone is not effective, both paracetamol and ibuprofen can be given alternately (i.e. ibuprofen can be taken first and then paracetamol 2 hours later, and so on, using the normal daily doses given in the prescription boxes above). This regimen controls ongoing pain and pyrexia without exceeding the recommended dose or frequency of administration for either drug. 47

54 7 Odontogenic Pain For mild to moderate odontogenic or inflammatory pain, an appropriate 5-day regimen is: Aspirin Dispersible Tablets, 300 mg Send: 40 tablets Label: 2 tablets four times daily, preferably after food <16 years Do not use in children because, rarely, it can cause Reye s syndrome 16 years As for adults NB: Advise patient that aspirin can be taken at 4-hourly intervals but not to exceed the recommended daily dose. In adults and children 16 years and over, up to 3 tablets (900 mg) can be given in one dose (maximum daily dose of 4 g). Do not prescribe aspirin following a dental extraction or other minor surgery. Avoid use in those with a known allergy to aspirin or hypersensitivity to aspirin or any other NSAID, including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by aspirin or any other NSAID. Avoid use in patients with previous or active peptic ulcer disease and use with caution in the elderly, patients with allergic disorders, pregnant women, nursing mothers, those taking oral anticoagulants such as warfarin, those with coagulation defects, those with an inherited bleeding disorder, and those with renal, cardiac or hepatic impairment. Aspirin is not licensed for use in children under 16 years (see Section 1.2). Diclofenac is also effective against moderate inflammatory or post-operative pain. An appropriate 5-day regimen is: Diclofenac Sodium Tablets, 50 mg Send: 15 tablets Label: 1 tablet three times daily Not recommended for dental use in children NB: Advise patient not to exceed the recommended daily dose (maximum of 150 mg). Avoid use in those with a hypersensitivity to aspirin or any other NSAID, including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by aspirin or any other NSAID. Do not prescribe for patients taking a low dose of aspirin daily. Avoid use in patients with previous or active peptic ulcer disease, unless a proton pump inhibitor is co-prescribed (see pg. 49), and use with caution in the elderly, patients with allergic disorders, pregnant women, nursing mothers, those taking oral anticoagulants such as warfarin, those with coagulation defects, those with an inherited bleeding disorder, and those with renal, cardiac or hepatic impairment. Diclofenac tablets are enteric coated and are therefore slower to act. Diclofenac tablets of >25 mg are not licensed for use in children (see Section 1.2). 48

55 7 Odontogenic Pain In patients who have a history of previous or active peptic ulcer disease where paracetamol alone is not sufficient for the treatment of odontogenic pain, and a NSAID (i.e. ibuprofen or diclofenac) is required, prescribe a proton pump inhibitor (i.e. lansoprazole and omeprazole) in conjunction with the NSAID. Prescribe the proton pump inhibitor for the duration of the analgesic course to prevent the occurrence of gastric problems. In patients who have a history of previous or active peptic ulcer disease and require a NSAID for the treatment of odontogenic pain, an appropriate 5-day regimen to prevent gastric problems is: Lansoprazole Capsules, 15 mg Send: 5 capsules Label: 1 capsule once daily Not licensed for children NB: Use with caution in patients with liver disease, in pregnancy and in patients who are breast-feeding. or Gastro-resistant Omeprazole Capsules, 20 mg Send: 5 capsules Label: 1 capsule once daily Not licensed for children NB: Use with caution in patients with liver disease, in pregnancy and in patients who are breast-feeding. 49

56 50

57 8 Facial Pain Before treatment, ensure the pain is not odontogenic in nature. Non-odontogenic facial pain can be organic or neurogenic in nature. Most non-odontogenic organic facial pain requires specialist care. 8.1 Trigeminal Neuralgia If a patient with trigeminal neuralgia presents in primary care, control quickly by treatment with carbamazepine. A positive response confirms the diagnosis. Make an urgent referral to a specialist or the patient s general medical practitioner for a full blood count and liver function tests to monitor for adverse effects, assess the response and titrate the dose. An appropriate 10-day regimen is: Carbamazepine Tablets, 100 mg Send: 20 tablets Label: 1 tablet twice daily Not relevant for children NB: Advise patient to space out doses as much as possible throughout the day. Carbamazepine has the potential to react with multiple other medicines; check appendix 1 of BNF for interactions. Carbamazepine can cause reversible blurring of vision, dizziness and unsteadiness (dose-related). 51

58 8 Facial Pain 8.2 Other Facial Pain Temporomandibular dysfunction usually responds to reassurance and local therapy; advise the patient to have a soft diet and avoid chewing gum, and consider making an occlusal splint for the patient. Acute temporomandibular dysfunction might respond to analgesics such as ibuprofen (see Section 7 for drug regimen) or a short course of diazepam as a muscle relaxant. However, as benzodiazepines are addictive and susceptible to abuse only the minimum number of tablets required should be prescribed. An appropriate 5-day regimen is: Diazepam Tablets, 2 mg Send: 15 tablets Label: 1 tablet 3 times daily Not recommended because it has an unpredictable effect in children NB: The dose can be increased if necessary to 15 mg daily. Halve the adult dose for elderly or debilitated patients. Advise all patients that they should not drive. If the patient does not respond, refer the patient to a specialist or the patient s general medical practitioner. Chronic neuropathic facial pain and oral dysaesthesia might require to be managed with neuropathic painkillers. Refer such cases to a specialist or the patient s general medical practitioner. 52

59 9 Mucosal Ulceration and Inflammation Mucosal ulceration and inflammation can arise as a result of several different conditions. A diagnosis must be established because the majority of lesions require specific therapy in addition to topical symptomatic therapy. Such specific therapy usually involves specialist care. Temporary relief using topical, symptomatic therapy involves simple mouthwashes, antimicrobial mouthwashes, local analgesics or topical corticosteroids. Review the patient to assess the status of ulcers. If ulcers remain unresponsive to treatment, refer the patient to a specialist. Any ulcer that persists for more than three weeks must be biopsied. 9.1 Simple Mouthwashes Local Measures to be used in the first instance Advise the patient to rinse their mouth with a salt solution prepared by dissolving half a teaspoon of salt in a glass of warm water to relieve pain and swelling. Alternatively, compound sodium chloride mouthwashes made up with warm water can be prescribed. An appropriate regimen is: Sodium Chloride Mouthwash, Compound Send: 300 ml Label: Dilute with an equal volume of warm water As for adults NB: Advise patient to spit out mouthwash after rinsing. 53

60 9 Mucosal Ulceration and Inflammation 9.2 Antimicrobial Mouthwashes Antimicrobial mouthwashes can reduce secondary infection and are particularly useful when pain limits other oral hygiene measures. An appropriate regimen is a choice of: Chlorhexidine Mouthwash, 0.2% Send: 300 ml Label: Rinse mouth for 1 minute with 10 ml twice daily As for adults NB: Advise patient to spit out mouthwash after rinsing and use until lesions have resolved and patient can carry out good oral hygiene. Chlorhexidine gluconate might be incompatible with some ingredients in toothpaste; advise patient to leave an interval of at least 30 minutes between using mouthwash and toothpaste. Also advise patient that chlorhexidine mouthwash can be diluted 1:1 with water with no loss in efficacy. or Chlorhexidine Oromucosal Solution, Alcohol-free, 0.2% Send: 300 ml Label: Rinse mouth for 1 minute with 10 ml twice daily >6 years As for adults NB: Advise patient to spit out mouthwash after rinsing and use until lesions have resolved and patient can carry out good oral hygiene. Chlorhexidine gluconate might be incompatible with some ingredients in toothpaste; advise patient to leave an interval of at least 30 minutes between using mouthwash and toothpaste. Also advise patient that chlorhexidine mouthwash can be diluted 1:1 with water with no loss in efficacy. or 54

61 9 Mucosal Ulceration and Inflammation Hydrogen Peroxide Mouthwash, 6% Send: 300 ml Label: Rinse mouth for 2 minutes with 15 ml diluted in half a glass of warm water three times daily As for adults NB: Advise patient to spit out mouthwash after rinsing, and use until lesions have resolved and patient can carry out good oral hygiene. Hydrogen peroxide mouthwash can be used as a rinse for up to 3 minutes, if required. A tetracycline mouthwash is effective in some patients with recurrent aphthous stomatitis. Doxycycline can be used as a rinse and is usually given for three days. Enough medication to treat several episodes of ulceration can be provided. An appropriate regimen is: Doxycycline Dispersible Tablets, 100 mg Send: 48 tablets Label: 1 tablet to be dissolved in water and rinsed around the mouth for 2 minutes four times daily for three days at the onset of ulceration <12 years Not recommended for use because it causes intrinsic staining of developing teeth 12 years As for adults NB: Advise patient to spit out mouthwash after rinsing. Use with caution in patients with hepatic impairment or those receiving potentially hepatotoxic drugs. Do not prescribe for pregnant women, nursing mothers or children under 12 years, as it can deposit on growing bone and teeth (by binding to calcium) and cause staining and, occasionally, dental hypoplasia. The anticoagulant effect of warfarin might be enhanced by doxycycline. Doxycycline is also available as doxycycline capsules. Doxycycline is not licensed for use in children under 12 years and doxycycline dispersible tablets are not licensed for oral ulceration in adults or children (see Section 1.2). 55

62 9 Mucosal Ulceration and Inflammation 9.3 Local Analgesics Local analgesics cannot relieve pain continuously but are helpful in severe pain (e.g. major aphthae) to enable eating or sleeping. Lidocaine 5% ointment can be directly applied to the ulcer or lidocaine 10% solution, provided as a spray, can be applied to the ulcer using a cotton bud. Benzydamine hydrochloride mouthwash or spray can also reduce mucosal discomfort. An appropriate regimen is a choice of: Benzydamine Mouthwash, 0.15% Send: 300 ml Label: Rinse or gargle using 15 ml every 1½ hours as required <12 years Not recommended for use because of local anaesthetic properties 12 years As for adults NB: Advise patient that benzydamine mouthwash can be diluted with an equal volume of water if stinging occurs. Advise patient to spit out mouthwash after rinsing. The mouthwash is usually given for not more than 7 days. or Benzydamine Oromucosal Spray, 0.15% Send: 30 ml Label: 4 sprays onto affected area every 1½ hours Benzydamine Oromucosal Spray, 0.15% 6 months 1 spray per 4 kg - 6 years body-weight (max. 4 sprays) every 1½ hours 6-18 years 4 sprays every 1½ hours NB: In adults and children of 12 years and over, up to 8 sprays of benzydamine oromucosal spray can be applied at any one time. or 56

63 9 Mucosal Ulceration and Inflammation Lidocaine Ointment, 5% Send: 15 g Label: Rub sparingly and gently on affected areas As for adults NB: Advise patient to take care with the application to avoid producing anaesthesia of the pharynx before meals as this might lead to choking. or Lidocaine Spray, 10% Send: 50 ml Label: Apply as necessary with a cotton bud As for adults NB: Advise patient to take care with the application to avoid producing anaesthesia of the pharynx before meals as this might lead to choking. Lidocaine Spray, 10%, is not licensed for oral ulceration (see section 1.2). 57

64 9 Mucosal Ulceration and Inflammation 9.4 Topical Corticosteroids Topical corticosteroids can be used to treat mucosal ulceration and inflammation. Carefully control chronic use to prevent systemic effects. The choice of preparation depends on the extent and location of the lesions. Hydrocortisone oromucosal tablets can be allowed to dissolve next to the lesion. Beclometasone diproprionate inhaler (Clenil Modulite ) sprayed twice daily onto the affected site is suitable for tongue lesions and accessible areas. Betamethasone tablets, dissolved in water and used as a mouthwash, are suitable for extensive inflammation or ulceration but should not be swallowed to minimise the risks of systemic effects. An appropriate regimen is a choice of: Clenil Modulite, 50 µg/metered inhalation (beclometasone pressurised inhalation, CFC-free) Send: One 200-dose unit Label: 1-2 puffs directed onto ulcers twice daily 2 years As for adults Clenil Modulite inhaler is not licensed for oral ulceration (see Section 1.2). or Betamethasone Soluble Tablets, 500 µg Send: 100 tablets Label: 1 tablet dissolved in 10 ml water as a mouthwash four times daily <12 years Not appropriate for use because of risk of swallowing 12 years As for adults NB: Advise patient to spit out mouthwash after rinsing. Betamethasone soluble tablets are not licensed for oral ulceration (see Section 1.2). or Hydrocortisone Oromucosal Tablets, 2.5 mg Send: 20 tablets Label: 1 tablet dissolved next to lesion four times daily <12 years Prescribe only on medical advice 12 years As for adults 58

65 10 Dry Mouth The subjective feeling of a dry mouth (xerostomia) can arise as a result of loss of the mucous layer without clinical evidence of dryness. There is usually little relief with artificial saliva preparations or mucosal gel preparations in these patients. Dry mouth can also be caused by drugs that have antimuscarinic effects (tricyclic antidepressants, antipsychotics), diuretic drugs, irradiation of the head and neck region or by damage or disease of the salivary glands (e.g. Sjörgen s syndrome). In these cases, artificial saliva preparations can provide useful relief Subjective Dryness but Good Saliva Volume Simple local measures (see below) might provide symptomatic relief in patients with subjective dryness but good saliva volume. However, usually little relief is provided by artificial saliva preparations or mucosal gel preparations and therefore the use of artificial saliva preparations is discouraged. Furthermore, preparations such as saliva-stimulating tablets (SSTs) or Salivix pastilles contain citric or malic acid and a very high frequency of use might lead to dental erosion. Local Measures to be used in the first instance Advise the patient to take frequent sips of cool drinks, suck pieces of ice or sugar-free fruit pastilles, or use sugar-free chewing gum to provide symptomatic relief Dry Mouth Induced by Head and Neck Radiotherapy Patients who have a true saliva deficit such as those undergoing head and neck radiotherapy are at high risk from dental caries and opportunistic infections. These patients should use topical fluoride preparations regularly (e.g. fluoride mouthwash, high-fluoride toothpaste) in addition to a saliva substitute or saliva-promoting medication. Pilocarpine can stimulate salivary flow in patients with some salivary function. However, this drug should only be prescribed by a specialist. Symptomatic relief can be obtained from the use of artificial salivas or other proprietary salivapromoting medication but the effects tend to be of short duration. Where there is a considerable reduction in saliva production the use of lubricant gel preparations, applied to the oral mucosa, can give more-prolonged relief. Discourage the use of sugar-containing sweets and drinks but sugar-free chewing gum might be helpful. As there is a lack of generic alternatives, the artificial salivas listed should be prescribed by brand name. 59

66 10 Dry Mouth An appropriate regimen is a choice of: An appropriate regimen is a choice of: AS Saliva Orthana Lozenges (this preparation does not contain fluoride supplementation) Send: 30 lozenges Label: 1 lozenge sucked as required Not relevant for children in dental setting or AS Saliva Orthana Oral Spray (this preparation includes limited fluoride supplementation) Send: 50 ml Label: Sprayed three times onto the oral mucosa as required Not relevant for children in dental setting or Biotène Oralbalance Salivareplacement Gel Send: 50 g Label: Apply to oral mucosa as required Not relevant for children in dental setting NB: Avoid use with toothpastes containing detergents (including foaming agents). or BioXtra Gel Send: 40 ml or Label: Apply to oral mucosa as required Not relevant for children in dental setting or 60

67 10 Dry Mouth Salivix Pastilles* Send: 50 pastilles Label: 1 pastille sucked as required Not relevant for children in dental setting *Sugar-free preparation is available. or Saliva-stimulating Tablets* (SSTs) Send: 100 tablets Label: 1 tablet sucked as required Not relevant for children in dental setting *Sugar-free preparation is available. and a choice of: Sodium Fluoride Toothpaste, 0.619% (2800 ppm) Send: 75 ml Label: Brush teeth for 1 minute after meals using 1 cm, before spitting out, twice daily 10 years Not indicated for use because of risk of swallowing and possible poisoning >10 years As for adults NB: Advise patient to avoid rinsing mouth, drinking or eating for 30 minutes after use, and advise patient that this 2800 ppm sodium fluoride toothpaste is a medicine and is only to be used by the person for whom it is prescribed. or 61

68 10 Dry Mouth Sodium Fluoride Toothpaste, 1.1% (5000 ppm) Send: 51 g Label: Brush teeth for 3 minutes after meals using 2 cm, before spitting out, three times daily 16 years Not indicated for use because of risk of swallowing and possible poisoning >16 years As for adults NB: Advise patient to avoid rinsing mouth, drinking or eating for 30 minutes after use, and advise patient that this 5000 ppm sodium fluoride toothpaste is a medicine and is only to be used by the person for whom it is prescribed. or Sodium Fluoride Mouthwash, 0.05% Send: 250 ml Label: Rinse mouth once daily with 10 ml for 1 minute and spit out (preferably at a different time from brushing) <6 years Not indicated for use because of risk of swallowing and possible poisoning 6 years As for adults NB: Advise patient to avoid rinsing mouth, drinking or eating for 15 minutes after use. 62

69 11 Dental Caries Fluoride confers significant resistance to dental caries, with the topical action of fluoride on enamel and plaque considered more important in this effect than the systemic action. Additional fluoride treatment is prescribed for patients who are at increased risk of dental caries or are medically compromised. The decision to prescribe additional fluoride treatment must take into account several factors, including whether the patient lives in an area where water is fluoridated, the concentration of fluoride contained in the toothpaste the patient uses, whether fluoride varnish has been applied and whether the patient uses fluoride rinses. Further advice is provided in the SDCEP Prevention and Management of Dental Caries in Children 11 guidance. In areas where the fluoride content of the drinking water is less than 0.7 ppm (0.7 mg per litre), daily administration of fluoride tablets or drops is a suitable means of supplementation. Do not prescribe systemic fluoride supplements without reference to the fluoride content of the local water supply. Additional protection can also be provided to patients by the use of fluoride varnish, fluoride rinses or high-fluoride toothpastes. If a systemic supplement is prescribed, an appropriate regimen for patients living in areas where the water fluoride content is less than 0.3 ppm (300 µg per litre) is: Sodium Fluoride Tablets, 1.1 mg (contain 500 µg F - ) Send: 60 tablets Label: 2 tablets (1 mg F - ), sucked or dissolved in the mouth daily (preferably in the evening and at a different time from brushing) Sodium Fluoride Tablets, 1.1 mg (contain 500 µg F - ) or Oral Drops* (0.37%; contain 36 µg F - per drop) 6 months µg F - daily 3 years (7 oral drops) 3-6 years 500 µg F - daily (1 tablet or 14 oral drops) 6-18 years 1 mg F - daily (2 tablets or 28 oral drops) NB: There is a risk of fluorosis if more than the recommended dose is taken at one time. Therefore, emphasize to patient (and parent or carer, where appropriate) the need for compliance with the recommended dosing regimen and advise patient not to double the dose if they miss a dose. Tablets and oral drops are normally prescribed for young children. The instances where tablets are prescribed for adults are rare. *Sugar-free preparation is available. 63

70 11 Dental Caries If a systemic supplement is prescribed, an appropriate regimen for patients living in areas where the water fluoride content is between 0.3 and 0.7 ppm ( µg per litre) is: Sodium Fluoride Tablets, 1.1 mg (contain 500 µg F - ) Send: 30 tablets Label: 1 tablet (500 µg F - ), sucked or dissolved in the mouth daily (preferably in the evening and at a different time from brushing) Sodium Fluoride Tablets, 1.1 mg (contain 500 µg F - ) or Oral Drops* (0.37%; contain 36 µg F - per drop) <3 years None because of risk of fluorosis 3-6 years 250 µg F - daily (7 oral drops) 6-18 years 500 µg F - daily (1 tablet or 14 oral drops) NB: There is a risk of fluorosis if more than the recommended dose is taken at one time. Therefore, emphasize to patient (and parent or carer, where appropriate) the need for compliance with the recommended dosing regimen and advise patient not to double the dose if they miss a dose. Tablets and oral drops are normally prescribed for young children. The instances where tablets are prescribed for adults are rare. *Sugar-free preparation is available. Do not prescribe systemic supplements (tablets, oral drops) for patients living in areas where the water fluoride content is >0.7 ppm (0.7 mg per litre). If a topical agent is prescribed, an appropriate regimen is a choice of: Sodium Fluoride Mouthwash, 0.05% Send: 250 ml Label: Rinse mouth once daily with 10 ml for 1 minute and spit out (preferably at a different time from brushing) or Sodium Fluoride Mouthwash, 0.05% <6 years Not indicated for use because of risk of swallowing and possible poisoning 6 years As for adults NB: Advise patient to avoid rinsing mouth, drinking or eating for 15 minutes after use. or 64

71 11 Dental Caries Sodium Fluoride Toothpaste, 0.619% (2800 ppm) Send: 75 ml Label: Brush teeth for 1 minute after meals using 1 cm, before spitting out, twice daily 10 years Not indicated for use because of risk of swallowing and possible poisoning >10 years As for adults NB: Advise patient to avoid rinsing mouth, drinking or eating for 30 minutes after use, and advise patient that this 2800 ppm sodium fluoride toothpaste is a medicine and is only to be used by the person for whom it is prescribed. or Sodium Fluoride Toothpaste, 1.1% (5000 ppm) Send: 51 g Label: Brush teeth for 3 minutes after meals using 2 cm, before spitting out, three times daily 16 years Not indicated for use because of risk of swallowing and possible poisoning >16 years As for adults NB: Advise patient to avoid rinsing mouth, drinking or eating for 30 minutes after use, and advise patient that this 5000 ppm sodium fluoride toothpaste is a medicine and is only to be used by the person for whom it is prescribed. 65

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73 12 Clinical Governance, CPD and Training It is a requirement of clinical governance and fundamental good clinical practice that all health professionals work to monitor and constantly strive to improve the quality of care that they and their teams provide to patients. It is recommended that: all general dental practitioners and dental care professionals involved in dealing with medical emergencies undertake appropriate annual training and continuing professional development (CPD); this is a practice inspection requirement and a minimum of 10 hours per CPD cycle is recommended by the General Dental Council (GDC); general dental practitioners who prescribe drugs ensure they are up to date with any changes in prescribing recommendations of the British National Formulary (BNF) and BNF for Children (BNFC); regular updates will be posted on the Scottish Dental Clinical Effectiveness Programme (SDCEP; website if required following publication of new editions of the BNF and BNFC, but practitioners should also refer to the BNF ( and BNFC ( for details; general dental practitioners who prescribe drugs seek to audit their practice regularly, and assess prescribing appropriateness and accuracy; examples of audit topics are provided in section 12.1; general dental practitioners who prescribe drugs carry out significant event analyses (SEAs) as appropriate. Further information on the training requirements for dealing with medical emergencies can be found in the SDCEP Practice Support Manual 5 ( Guidance concerning audit and significant event analysis can also be found in the Practice Support Manual 5 or is available via NHS Education for Scotland ( 67

74 12 Clinical Governance, CPD and Training 12.1 Recommendations for Self Audit The terms of service for dentists in Scotland 12 state that GDPs should undertake at least 15 hours of clinical audit within each three year period, the first of which commenced on 1st August Drug prescribing is an area where audit can be a particularly useful tool for improving patient care. Topics for audit and review should be chosen carefully to provide information that will improve the quality of drug prescribing within dentistry and ensure patient safety. Examples include: the appropriateness of prescribing (i.e. is the prescribed drug appropriate for the condition?); the accuracy and completeness of prescriptions (i.e. is the correct dose and frequency included, and are all relevant details included?) National Audit The Translation Research in a Dental Setting (TRiaDS) programme (follow the TRiaDS link at www. sdpbrn.org.uk) is a multi-disciplinary research collaboration that aims to develop and evaluate strategies to improve the translation of guidance recommendations into dental practice. TRiaDS is conducting analyses of prescribing patterns to evaluate the impact of this guidance, to inform the development of national audits and to determine if there is a need for further implementation strategies. 68

75 Appendix 1 Guidance Development The Scottish Dental Clinical Effectiveness Programme The Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative of the National Dental Advisory Committee (NDAC) in partnership with NHS Education for Scotland. The NDAC comprises representatives of all branches of the dental profession and acts in an advisory capacity to the Chief Dental Officer. It considers issues that are of national importance in Scottish dentistry and also provides feedback to other bodies within the Scottish Government on related, relevant healthcare matters. SDCEP was established in 2004 under the direction of the NDAC to give a structured approach to providing clinical guidance for the dental profession. The programme s primary aim is to develop guidance that supports dental teams to provide quality patient care. SDCEP brings together the best available information that is relevant to priority areas in dentistry, and presents guidance on best practice in a form that can be interpreted easily and implemented. The guidance recommendations may be based on a variety of sources of information, including research evidence, guidelines, legislation, policies and expert opinion as appropriate to the subject. SDCEP guidance takes a variety of forms to suit the diverse topics being addressed. Recognising that publication of guidance alone is likely to have a limited influence on practice, SDCEP also contributes to the research and development of interventions to enhance the translation of guidance recommendations into practice through its participation in the TRiaDS (Translation Research in a Dental Setting) collaboration (follow the TRiaDs link at SDCEP is funded by the Scottish Government Health Directorates and through its collaboration with NHS Education for Scotland contributes to the implementation of the Scottish Government s Dental Action Plan, which aims to both modernise dental services and improve oral health in Scotland. 69

76 Appendix 1 Guidance Development The Guidance Development Group A Guidance Development Group, comprising individuals from a range of branches of the dental profession that have a role in dental drug prescribing, was convened to develop and write this guidance. David Wray (Chair) Eric Battison Tony Coia Alex Crighton Petrina Sweeney Professor of Oral Medicine, University of Glasgow Dental Hospital and School Dental Practice Advisor, Lothian General Dental Practitioner, Glasgow Consultant in Oral Medicine, Glasgow Dental Hospital and School; member of the Scottish Antimicrobial Prescribing Group Senior Lecturer/Honorary Consultant in Special Care Dentistry, University of Glasgow Dental School 70

77 Appendix 1 Guidance Development The Programme Development Team The Guidance Development Group works closely with the Programme Development Team, which provides project management and administrative support and is responsible for the methodology of guidance development. The team facilitates all aspects of guidance development by searching and appraising information and evidence, conducting research, liaising with external organisations, editing the guidance, and managing the publication and dissemination of guidance materials. Jan Clarkson Douglas Stirling Professor of Clinical Effectiveness, University of Dundee; SDCEP Director Programme Manager Guidance and Programme Development Samantha Rutherford Research and Development Manager Guidance Development and lead for Drug Prescribing For Dentistry 2nd Edition Linda Young Joseph Liu Jill Farnham Liz Payne Trish Graham Research and Development Manager Evaluation of Implementation Senior Research Fellow Administrator Administrator Administrator The Guidance Development Group and the Programme Development Team are particularly grateful to the late Dr Gillian MacKenzie for her invaluable contribution to the development of the SDCEP Drug Prescribing For Dentistry guidance. 71

78 Appendix 1 Guidance Development Guidance Development Methodology SDCEP endeavours to use a methodology for guidance development that mirrors that used to develop high-quality guidelines. It aims to be transparent, systematic and to adhere as far as possible to international standards set out by the Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration ( For this guidance on drug prescribing, the British National Formulary and BNF for Children were used as the main sources of information. These publications aim to provide prescribers, pharmacists and other healthcare professionals with sound up-to-date information about the use of medicines. Information about drugs included in these publications is drawn from the manufacturers product literature, medical and pharmaceutical literature, regulatory authorities and professional bodies. Advice is constructed from the clinical literature and reflects, as far as possible, an evaluation of the evidence from diverse sources. The Guidance Development Group identified information from the BNF and BNFC, and consulted with experts and experienced practitioners to develop guidance of specific relevance to primary care dental practice. For those drugs where a range in the dose or frequency of administration is provided by the BNF, a dose and frequency of administration that is most relevant to primary care dental practice is recommended based on the opinion of experienced practitioners. Other references used in the production of the current guidance are cited in the reference list. For the first edition of this guidance, a wide consultation was conducted prior to peer review and publication. This included a wide range of individuals and organisations with particular interests in dental prescribing, representatives of end-users and those involved in the organisation of dental services or dental education in Scotland. The content and presentation of the second edition of the guidance does not vary significantly from that of edition one. Therefore it was concluded that in depth consultation was not required. The updated guidance was reviewed by the Guidance Development Group before peer review by a range of experts comprising general dental practitioners, academic dentists, pharmacists and medical professionals, including paediatricians. Comments received during peer review were considered carefully by the Guidance Development Group and further amendments were made to the guidance before publication. Further information about the methodology used to develop this guidance is available on our website: Declarations of interest are made by all contributors to SDCEP. Details are available on request. 72

79 Appendix 1 Guidance Development Review and Updating A review of all aspects of the context of this guidance (regulations, legislation, trends in working practices and evidence) will take place three years after publication and, if this has changed significantly, the guidance will be updated accordingly. As with edition one, the prescribing guidance in edition two will be reviewed as each new edition of the BNF and BNFC is released, with updates available on the SDCEP website ( and, if required, as a hard copy to be stored in the pocket at the rear of this publication. 73

80 Appendix 1 Guidance Development Steering Group The Steering Group oversees all the activities of the SDCEP and includes representatives of each guidance development group and the dental institutions in Scotland. Jeremy Bagg (Chair) Graham Ball Jan Clarkson Dafydd Evans Richard Ibbetson Alice Miller James Newton Nigel Pitts Derek Richards Nigel Robb William Saunders Alan Whittet David Wray Chairman of the National Dental Advisory Committee; Head of Glasgow Dental School; Professor of Clinical Microbiology, University of Glasgow Consultant in Dental Public Health, Fife Director, Scottish Dental Clinical Effectiveness Programme; Professor of Clinical Effectiveness, University of Dundee Senior Lecturer and Consultant in Paediatric Dentistry, Dundee Dental Hospital and School, University of Dundee Clinical Director, Edinburgh Postgraduate Dental Institute; Professor of Dental Primary Care, University of Edinburgh General Dental Practitioner, Duns, Borders; VT Adviser, NHS Education for Scotland Director of Aberdeen Dental School; Professor, University of Aberdeen Professor of Dental Health and Director, Dental Health Services Research Unit, University of Dundee Specialist Advisor to the SDCEP Programme Development Team; Consultant in Dental Public Health, Forth Valley; Director of the Centre for Evidence-Based Dentistry, Oxford Senior Lecturer in Sedation in Relation to Dentistry, University of Glasgow Dental School Dean of the Dental School; Professor of Endodontology, University of Dundee General Dental Practitioner, Longniddry, Lothian; Dental Practice Adviser, NHS Lothian Professor of Oral Medicine, University of Glasgow Dental School 74

81 Appendix 2 List of Drugs The following drugs are included in the second edition of Drug Prescribing For Dentistry. All drugs in this guidance can be prescribed by dentists within the NHS in Scotland (see List of Dental Preparations in BNF 61 1 ). Please refer to Appendix 1 of the British National Formulary (BNF; and BNF for Children (BNFC; for further details of drug interactions. Report any suspected adverse interactions to the Medicines and Healthcare products Regulatory Agency (see the BNF for details). Aciclovir Cream Aciclovir Oral Suspension, 200 mg/5 ml Aciclovir Tablets, 200 mg Aciclovir Tablets, 800 mg Amoxicillin Capsules Amoxicillin Oral Suspension AS Saliva Orthana Lozenges AS Saliva Orthana Oral Spray Aspirin Tablets, Dispersible Beclometasone Diproprionate Aerosol Inhalation, 50 µg/metered dose as Clenil Modulate Benzydamine Mouthwash, 0.15% Benzydamine Oromucosal Spray, 0.15% Betamethasone Soluble Tablets, 500 µg Biotène Oralbalance Saliva-replacement Gel BioXtra Gel Carbamazepine Tablets Chlorhexidine Mouthwash Chlorhexidine Oromucosal Solution, Alcoholfree, 0.2% Clarithromycin Oral Suspension, 125 mg/5 ml Clarithromycin Oral Suspension 250 mg/5 ml Clarithromycin Tablets Clindamycin Capsules Co-amoxiclav Tablets 250/125 (amoxicillin 250 mg as trihydrate, clavulanic acid 125 mg as potassium salt) Diazepam Tablets Diclofenac Sodium Tablets Doxycycline Capsules, 100 mg Doxycycline Dispersible Tablets Ephedrine Nasal Drops Erythromycin Ethyl Succinate Oral Suspension Erthyromycin Tablets Fluconazole Capsules, 50 mg Fluconazole Oral Suspension, 50 mg/5 ml Hydrocortisone Oromucosal Tablets Hydrogen Peroxide Mouthwash Ibuprofen Oral Suspension, sugar-free Ibuprofen Tablets Lansoprazole Capsules Lidocaine 5% Ointment Lidocaine Spray 10% Metronidazole Oral Suspension Metronidazole Tablets Miconazole Cream Miconazole Oromucosal Gel Miconazole and Hydrocortisone Cream Miconazole and Hydrocortisone Ointment 75

82 Appendix 2 List of Drugs Nystatin Oral Suspension Omeprazole Gastro-Resistant Capsules Paracetamol Oral Suspension Paracetamol Tablets Paracetamol Tablets, Soluble Penciclovir Cream Phenoxymethylpenicillin Oral Solution Phenoxymethylpenicillin Tablets Saliva-stimulating Tablets Salivix Pastilles Sodium Chloride Mouthwash, Compound Sodium Fluoride Mouthwash Sodium Fluoride Oral Drops Sodium Fluoride Tablets Sodium Fluoride Toothpaste 0.619% Sodium Fluoride Toothpaste 1.1% Sodium Fusidate (fusidic acid) Ointment 76

83 Appendix 3 Useful Sources of Information The British National Formulary (BNF) and BNF for Children (BNFC) have been the main information sources used in the development of this guidance. In addition to providing information on drug prescribing and drugs used to manage medical emergencies, the BNF also contains other useful information, including: Contact details for medicines information services (also see overleaf) and poisons information services Guidance on prescribing Information on prescription writing Details of controlled drugs and drug dependence Advice on adverse reactions, including the oral side-effects of drugs, and how to report new adverse reactions to the Medicines and Healthcare products Regulatory Agency Information on: - prescribing for children - prescribing for patients with liver disease - prescribing for patients with renal impairment - prescribing for pregnant patients - prescribing for breastfeeding patients - prescribing for the elderly Information on drug interactions (Appendix 1 of BNF and BNFC) A table showing the mean weights of children by age (also see overleaf) In addition information on prescribing for specific patient groups is included in the relevant chapters, either under the specific drug or in the prescribing notes. 77

84 Appendix 3 Useful Sources of Information Medicines Information Services Information on any aspect of drug therapy can be obtained from regional and local Medicines Information Services. For example, the Information Services can provide advice on the choice of drugs, interactions, adverse reactions and restrictions on drug prescribing. Details of the local services provided within Scotland can be obtained from the directory on the UK Medicines Information website ( or by telephoning one of the following regional numbers. Aberdeen: Dundee: or Extn Edinburgh: Glasgow: Information on drug therapy relating to dental treatment can be obtained by telephoning the North West Medicines Information Centre ( Telephone:

85 Appendix 3 Useful Sources of Information Prescribing for Children Mean Weights The information in the table below has been extracted from BNFC The table shows the mean values for weight by children s age. These values can be used to calculate doses in the absence of actual measurements. However, note that the child s actual weight might vary considerably from the values in the table and it is important to see the child to ensure that the value chosen is appropriate. In most cases, the child s actual weight should be obtained as soon as possible and the dose re-calculated. Age Weight (kg) 6 months year 9 3 years 14 5 years 18 7 years years years year old boy year old girl 50 Adult male 68 Adult female 58 79

86 80

87 Index Principal page references are highlighted in bold (e.g. pages on which prescription boxes for a particular drug are presented and pages on which a particular condition is discussed). Abscess, dental 26, 28, 29 local measures 26 Aciclovir 41, 43, 44 Acute coronary syndrome see Angina and Myocardial Infarction Acute necrotising ulcerative gingivitis 25, 31 local measures 31 Adrenaline 7, 9 Allergy 10 Amoxicillin 26, 27, 29, 31, 32, 33 Anaphylaxis 9 Angina 13 Angular cheilitis 39 Antibiotic prophylaxis 26 Antibiotics 25, 26, 29 Antifungal agents 35, 37 Antihistamine 11 Anxiety 23 Artificial saliva preparations 59 AS Saliva Orthana 60 Aspiration 21 Aspirin 7, 14, 45, 48 Asthma 12 Beclometasone diproprionate Clenil Modulite 58 Bell s palsy 41 Benzodiazepine 23 Benzydamine 41, 56 Betamethasone 58 Biotène Oralbalance 60 BioXtra 60 Candidal leukoplakia 35 Candidosis, erythematous 35 local measures 35 Candidosis, pseudomembranous 35 local measures 35 Candidosis,chronic hyperplastic 35 Carbamazepine 51 Cardiac arrest 14 Cardiac emergencies 13 Cetirizine 8, 10 Chlorphenamine 8, 10 Choking 21, 22 Clarithromycin 29, 30 Clindamycin 29 Clostridium difficile 25, 29 Co-amoxiclav 29, 30 Contraceptives 3, 25 Corticosteroids 53, 58 Dental caries 63 Diazepam 23, 52 Diclofenac 45, 48 Doxycycline 34, 55 Dry mouth 59 local measures 59 Dry socket 25 Ephedrine 33 Epilepsy 15 Erythromycin 28, 29 Faint 17 Famciclovir 44 Fluconazole 35, 36, 38 Fluoride Tablets 63, 64 Toothpaste 59, 61, 62, 65 Gingivitis see Acute necrotising ulcerative Glucagon 7, 19 Glucose oral 7, 18, 19 Glyceryl trinitrate (GTN) 7, 13 Herpes labialis 41, 43 Herpes simplex virus 41 local measures 41 Herpes zoster 44 Herpetic gingivostomatitis 41 Hydrocortisone 58 Hypoglycaemia 18 Ibuprofen 45, 47, 52 81

88 Index Infection Bacterial 25, 26 Fungal 35 Viral 41 Infective endocarditis 26 Inflammation Mucosal 53, 58 Palatal 37 Lansoprazole 49 Lidocaine 56, 57 Local analgesics 53, 56 Loratadine 8, 11 Medical emergencies 2, 7 Metronidazole 28, 29, 31 Miconazole 35, 36, 38, 39, 40 Miconazole and Hydrocortisone 40 Midazolam 7, 8, 16 Mouthwash Antimicrobial 41, 53 Benzydamine 56 Chlorhexidine 37, 41, 42, 54 Chlorhexidine alcohol free 54 Doxycycline 55 Hydrogen peroxide 41, 42, 55 Simple 53 Sodium chloride 53 Sodium fluoride 59, 62, 64 Tetracycline 55 Myocardial infarction 13 NSAID 45, 49 Nystatin 35, 37, 39 Omeprazole, gastro-resistant 49 Oxygen 7, 9, 12, 13, 14, 15, 17, 18, 20, 21 Pain Facial 51 Inflammatory 47, 48 Neuropathic 52 Odontogenic 45, 46, 47, 48 Oral dysaesthesia 52 Other 52 Post-operative 45, 46, 47, 48 Paracetamol 46, 47 Penciclovir 43 Penicillin 27, 29 Pericoronitis 25, 31 local measures 31 Phenoxymethylpenicillin 26, 27, 29 Pilocarpine 59 Premedication 23 Pulpitis 25 Pyrexia 28, 45, 47 Salbutamol 7, 11, 12, 21 Saliva-stimulating tablets (SSTs) 59, 61 Salivix pastilles 59, 61 Sedation 23 Shingles see Herpes zoster Sinusitis 25, 32 local measures 32 Sodium fusidate (fusidic acid) 39, 40 Stomatitis, aphthous 55 Stomatitis, denture 37, 39 local measures 37 Stroke 20 Swelling 25, 26, 31 Temporomandibular dysfunction 52 Topical corticosteroids see Corticosteroids Trigeminal neuralgia 51 Trismus 25, 26 Ulceration, mucosal 53, 58 local measures 53 Valaciclovir 44 Xerostomia (dry mouth) 59 82

89 References 1 Joint Formulary Committee. British National Formulary, Edn. 61, London. British Medical Association and Royal Pharmaceutical Society of Great Britain (2011) ( 2 Paediatric Formulary Committee. BNF for Children, London. British Medical Association, Royal Pharmaceutical Society of Great Britain, Royal College of Paediatrics and Child Health, and Neonatal and Paediatric Pharmacists Group (2011) ( 3 Medical Emergencies and Resuscitation. Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice. Resuscitation Council (UK) (2006, revised and updated 2011) ( 4 National Dental Advisory Committee. Emergency Dental Drugs. The Scottish Office Department of Health (1999) 5 Practice Support Manual: Dental Practice Guidance. Scottish Dental Clinical Effectiveness Programme (website) ( 6 Oral Health Management of Patients Prescribed Bisphosphonates: Dental Clinical Guidance. Scottish Dental Clinical Effectiveness Programme (2011) ( 7 Emergency Treatment of Anaphylactic Reactions. Guidelines for Healthcare Providers. Resuscitation Council (UK) (2008) ( 8 Conscious Sedation in Dentistry: Dental Clinical Guidance. Scottish Dental Clinical Effectiveness Programme (2006) ( 9 Drug Interactions with Hormonal Contraception: Clinical Guidance. Faculty of Sexual & Reproductive Healthcare (2011) ( 83

90 References 10 NICE Clinical Guideline 64. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. National Institute for Health and Clinical Excellence (2008) ( 11 Prevention and Management of Dental Caries in Children: Dental Clinical Guidance. Scottish Dental Clinical Effectiveness Programme (2010) ( 12 Terms of Service for Dentists. Schedule 1 of The National Health Service (General Dental Services) (Scotland) Regulations SSI 2010/208 ( 84

91 Notes 85

92 Notes 86

93 Scottish Dental Clinical Effectiveness Programme SDcep Other guidance from SDCEP: Conscious Sedation in Dentistry Decontamination into Practice Emergency Dental Care The Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative of the National Dental Advisory Committee (NDAC) and is supported by the Scottish Government and NHS Education for Scotland. The programme aims to provide userfriendly, evidence-based guidance for the dental profession in Scotland. SDCEP guidance is designed to help the dental team provide improved care for patients by bringing together, in a structured manner, the best available information that is relevant to priority areas in dentistry, and presenting this information in a form that can interpreted easily and implemented. Supporting the dental team to provide quality patient care Prevention and Management of Dental Caries in Children Practice Support Manual Oral Health Assessment and Review Oral Health Management of Patients Prescribed Bisphosphonates Further details are available on the SDCEP website:

94 The Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative of the National Dental Advisory Committee and is supported by the Scottish Government and NHS Education for Scotland. The Programme aims to provide user-friendly, evidence-based guidance for the dental profession in Scotland. SDCEP guidance is designed to help the dental team provide improved care for patients by bringing together, in a structured manner, the best available information that is relevant to priority areas in dentistry, and presenting this information in a form that can be interpreted easily and implemented. The second edition of Drug Prescribing For Dentistry aims to facilitate drug prescribing within primary care dental practice. Advice on dental prescribing from the British National Formulary (BNF) and BNF for Children is presented it in a readily accessible, problem-oriented style. Scottish Dental Clinical Effectiveness Programme Dundee Dental Education Centre, Frankland Building, Small s Wynd, Dundee DD1 4HN [email protected] Tel / Website